High blood pressure and cholesterol treated more aggressively in elderly heart attack patients than elderly diabetes patients

A new study from the Institute for Clinical Evaluative Sciences (ICES) has found that, in Ontario, medications to control high blood pressure and cholesterol are used less in elderly individuals following a diabetes diagnosis than in those who have had a first heart attack, despite the fact that both groups are at similar risk for mortality.

“Although clinical practice guidelines recommend that the same or lower blood pressure and cholesterol targets be applied for diabetic patients as for secondary prevention following a heart attack, our results show that this is often not done in actual practice,” said Dr. Baiju Shah, ICES scientist and lead author of the study.

ICES researchers tracked Ontarians 65 years of age and older with no history of heart attack or diabetes, and among these individuals, two groups were assembled: those who had a first heart attack between 2000 and 2002, and those first diagnosed with diabetes during the same time period. They determined whether patients received prescriptions for antihypertensive and lipid-lowering drugs before and after either the heart attack or the diabetes diagnosis.

During the study period, there were 9,742 people with a first heart attack and 38,947 people who were diagnosed with diabetes. Patients who developed diabetes were more likely to have been taking antihypertensive or lipid-lowering medications before diagnosis, while patients who had a heart attack were less likely to have been taking these medications prior to the heart attack.

However, after a heart attack, 96% of patients were prescribed antihypertensive drugs versus 75% of people after a diagnosis of diabetes, while lipid-lowering drug use rose to 70% in heart attack patients versus only 41% in diabetes patients. This difference persisted, although it narrowed over time.

“There are several possible explanations for our results,” said Dr. Shah.

“Heart attacks may be viewed as an acute life-changing event, whereas diabetes may be seen as a manageable chronic disease. As well, since coronary risk reduction may have greater relevance for patients who have undergone a coronary event, heart attack patients and their physicians may be more motivated to initiate and adhere to risk reduction.

“Furthermore, in-hospital heart attack care is often driven by specific steps that are taken by physicians in treating these patients, which may improve prescribing practices, while diabetes care is usually delivered in a less structured ambulatory setting. Finally, ongoing acute management issues in diabetes, like blood sugar control, may distract from addressing longer-term risk reduction.”

Dr. Shah stresses, however, that “the undertreatment of coronary risk for patients with diabetes is an important gap in the quality of care of these high-risk patients that should be addressed.”

The study, “Diabetes is not treated as a coronary artery disease risk equivalent”, is in the February 2007 issue of the journal Diabetes Care.

Author affiliations: ICES (all authors); Division of Endocrinology (Dr. Shah), Department of General Internal Medicine (Dr. Hux), Sunnybrook Health Sciences Centre; Department of Medicine (Drs. Shah and Hux), Departments of Public Health Sciences and Health Policy, Management and Evaluation (Dr. Austin), University of Toronto.

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy. 

FOR FURTHER INFORMATION, PLEASE CONTACT:

• Julie Dowdie
• Media Relations Officer, ICES
• (416) 480-4780 or cell (416) 432-8143